El lenguaje como mediación expresiva de la conciencia

There were differences in management styles between private and public healthcare organisations in Hong Kong. The public managers and GPs described themselves as

‘staff’, who were expected to support the initiatives and comply with the regulations set by the public organisation. Several participants reported that their clinical practices were bound by a series of resource allocation policies established by the government and other lists of corporate goals, as well as service standards and public accountability by the HA. One public GP argued that the clinical team was facing dual pressure from the HA and from increased expectations by the public to provide a better quantity and quality of care. In the accounts of many public GPs and managers, they felt unvalued and powerless in corporate decisions as the top management did not take their expressed concerns and feedback on resource allocation and welfare changes seriously. This view was echoed by a manager, who felt that frontline staff were expected to follow instructions as given with little voice in corporate policy such as the Hospital Accreditation Programme: “Actually…the frontline staff are not that interested in the

134 Hospital Accreditation Programme⁵, they are just being forced into it, aren’t they?” (M2, public manager). Some public GPs also felt disconnected and excluded by top management in the purchasing decisions for chronic disease medications. For example, one public GP struggled against the HA prescription guidelines which prohibited him from offering the best available option to patients with complex physical and mental conditions: “In fact there are many constraints in prescriptions. You know of some good medications, but you can’t prescribe them. You see that patients are emotionally unstable, but you can’t help them with their other problems…” (P5, public GP). Another public GP said they could only prescribe a limited range (60% of the market stock) of the chronic disease medications available in the HA pharmacy without additional charges. In this way, public GPs were trained explicitly to adhere to prescription rules for clear-cutting first, second and third line therapies⁶ and told patients only about the options available to them (Hong Kong Hospital Authority, 2015a). Whilst some public GPs and one manager felt that it was somewhat unethical to adhere to the HA formulary, all agreed that the formulary considered cost-saving weighted by patient benefits in categorising first-, second- and third- line therapies (Hong Kong Hospital Authority, 2015a). One senior manager admitted that conflict arose between GPs and patients when the HA purchasing guidelines prevented them from prescribing the most clinically effective medication to patients, instead of shifting them to prescribe a generic or a less expensive option as the first treatment:

5The Hospital Accreditation Programme is the first accreditation programme supported by the HA, in collaboration with the Government, Department of Health and Private Hospitals Association, since 2009 to assess the hospitals’ performance based on international practices, standards and principles from The International Society for Quality in Health Care (Hong Kong Hospital Authority, 2018b).

6 First line therapy is proven to be the most cost-effective drug in terms of cost, safety and efficacy reviewed and approved by drug and utilisation policies in the HA Drug Formulary, a committee that is accountable for drug policies, guidelines, management and utilisation across public hospitals and clinics (Hong Kong Hospital Authority, 2015a).

135 Patients know about it. They would ask, why don’t you prescribe me the nicer drugs with fewer side effects and hypoglycemia? However, we cannot prescribe the DPP4 group; it is a third line drug. Conflicts arise between GPs and patients when it comes to drug formulary guidelines related issues. It happens. (M2, public manager).

To minimise conflicts, some public managers and GPs explicitly avoided introducing or providing further information on second- or third-line drugs, as described by a public manager: “Sometimes we tell patients who ask about second- or third-line drugs: ‘We will see by the time you need them’. You do not need to say too much; just give them the appropriate amount of information” (M2, public manager). Moreover, a few public GPs and managers, particularly resisted offering self-funded medications as it risked losing trust and creating conflicts with patients from lower socioeconomic class

“patients who visit the HA are not rich. Of course, there are expectations, but they become hostile when you suggest some out-of-pocket payment for medications in the private market” (P5, public GP).

Conversely, some private GPs and managers described GPs as “partners” within a private organisation. Private managers elaborated on the partners’ contributions in which the organisation provided structural support such as pharmaceutical procurement, facilities development and management and pooling of patients from insurers or corporate medical benefits to sustain the GPs’ revenue. They also said the GPs’ job is to keep the business going, retaining and attracting new customers with their professional skills. Through an engaging management style, private managers engaged GPs actively in corporate decisions across clinic operations, management pricing and drug procurement aspects of the business in return for their loyalty in staying in the

136 workforce: “It is a partnership because doctors are professionals. They need respect.

Although they are fully employed in our organisation, we still give them a lot of autonomy to build up a good workforce and have continuity!” (M5, private manager).

Private GPs were not restricted by the prescription guidelines from the HA drug formulary and had a higher sense of ownership and autonomy to prescribe any type of medication affordable for the patients. In the accounts of patients with unfamiliar demands, private GPs showed more understanding, considering the clinical effectiveness as well as the long-term psychosocial burden of the medication. A private manager stated:

From the patients’ perspective, they should have autonomy. We will tell patients the drug’s cost, the benefits and risks of their current medication and other alternatives. If patients think it’s too expensive to purchase medication in our clinic, we will write them a prescription to purchase it elsewhere. We will still prescribe them the drug if they cannot find a cheaper alternative elsewhere (M1, private manager).

Returning to the concerns of “resistant patients” described by public GPs, private GPs were more open-minded when patients rejected their prescription offer, and still attended to their worries about future harm from various treatment plans. They even took one step further to refer or extend a future offer of prescription. For example, a private GP recounted how he handled patients worrying about unprecedented potential side effects: “sometimes we tell the patients: if you feel unwell after the medication and you think it is related to the medication itself, you are welcome to telephone me” (P7, private GP).

137 As indicated previously in relation to the differences in management style between the public and private sectors, a private manager commented that the rigid style of management in the public sector was hampering the long-term GP-patient relationship:

It might be different in the public sector because if you refer the patients out [to the private sector], they cannot go back to the public clinic. However, our organisation is supportive. If patients trust a specialist and want to see them instead, the GPs will refer them to specialists in our organisation to get a second opinion, or they can be transferred back to the GP. Our GPs and specialists can meet their quotas (M5, private manager).

A common understanding shared by the private GPs was that they could refer the patients back to the public sector at times when they felt that the patients’

complication risk would be high, and consequences may be severe. In contrast, some public GPs reported having to take full responsibility for all the patients until the very last moment when there was a clear surgical need, and fear of being blamed if patients reported side effects from medications: “As simple as medication may be, there are still some known side effects. There is a trend where if side effects occur, we are blamed for doing harm to the patients” (P3, public GP). The constraints of prescription guidelines, which limit the range of medications available to patients, and fear of conflicts or blame led public GPs to provide the minimal amount of clinical information listed on hospital guidelines. Private GPs without such restrictions felt more confident to disclose more drug information even when patients rejected their prescriptions or requested unfamiliar medication.

138 4.3.2.3 Subtheme 2.3: GPs’ perception of learning culture and how this influences their readiness to use patient-centred consultation styles

This section describes how the norms of medical training within an organisation lead to a disparity of views between public and private GPs on their professional role, values and readiness to use patient-centred consultation styles.

In Hong Kong, public and private GPs are educated in the same way through their undergraduate and internship years at two medical schools which shape their professional identity and core professional values. However, their work experience in public and private practices transformed some of their professional identity and values.

For example, one private GP perceived himself as a “problem solver” (P12, private GP), while others saw themselves as a “health coach” (P6, public GP & M4, private manager) and “medical healers” (M3, public manager, P6, public GP & M4, private manager).

Some public managers and private GPs emphasised the first ‘do no harm’ principle as they saw it as their duty to address patients’ health beliefs about medications if they appeared irrational or unreasonable. Other GPs who identified themselves as family medicine (FM) specialists saw themselves as “better communicators” than those without this training.

Although public and private GPs go through the same medical education, the learning culture and on-the-job training appeared to be different, shaping GPs’ unique way of building rapport, consulting and making treatment decisions with patients. Some public managers reported that public GPs are expected by the HA to undergo family medicine training as a mandatory process, equipping themselves with essential patient-centred consultation skills in order to qualify as a specialist in family medicine. Thus, the public hospitals were being allocated with government resources to develop formalised

139 training programmes and policies. In this formalised training programme, most public GPs are given extra coaching to strengthen patient-centred skills through observation, supervision, regular assessment and feedback from senior colleagues. The majority of public GPs referred to this coaching as a gateway to refining the level of patient-centeredness and effectiveness of their consultation skills, providing them with extra reassurance for their future FM exams. Unfortunately, the government training resources were not allocated to or benefited the private GPs. Other responses from most of the private GPs and one public GP illustrated that they learnt most of their skills through personal experience. Without the resources for formalised coaching in the private sector, a public manager revealed that some private GPs secretly visited and learned from their high-performing private competitors:

You know some GPs pretend to be patients and consult their competitors? They spent HK$200-300 (£20-30 sterling) because they wanted to know why the GPs next door have a thriving business while they themselves have no customers.

They can go and see it, wow! Their clinic has long queues. Wow…fully booked.

(M2, public manager).

Some GPs reported they also acquired their skills through feedback from senior colleagues, professional seminars and previous family medicine training in the public sector or college. Some private GPs who had family medicine training felt readier to use the patient-centred consultation style to explore the ideas, concerns, and expectations of patients across physical, emotional and social aspects of their conditions.

Many public GPs, and both public and private managers, also reported feeling ready to reach mutual decisions with patients. Two managers commented that GPs gradually increased their level of confidence through the FM training process. In the public sector, trainees implemented various aspects of patient-centred skills targeting physical

140 examination, needs assessment and disease management by shifting the power back to the patients in exploring, negotiating and reaching clinical decisions.

In the private sector, organisations did not expect GPs to train as specialists nor deliver patient-centred consultations. Two private GPs reported having full control to use the right consultation style to satisfy patients and pointing out that their organisation was flexible on FM training. The learning culture is driven by GPs’ motivation and incentives. One manager (M4, college manager) argued that training resources skewed towards the public sector left the private GPs with little incentive or opportunity to obtain advanced training in family medicine. Some GPs and managers felt that existing private GPs were not keen on the FM Programme as they would be sacrificing their job security without a guaranteed revenue gain as an FM specialist in the private sector upon completion of the Programme. Another manager claimed that younger GPs entering the private sector directly after graduation without FM training would, therefore, bombard their patients with a doctor-centred style: “GPs who just graduated;

most of them use this paternalistic model: ‘this is how I would do it’… to give orders dadada, bumbumbum like this and not care about patients’ thoughts” (M2, public manager). One manager argued that on rare occasions without FM coaching, some GPs may be able to “figure it out on their own” (M2, public manager) and deliver satisfying patient-centred care. Another private manager added GPs’ character, attributes, previous training and years of clinic experience determine their readiness for SDM, but most private GPs are not given a chance to develop and refine their consultation style.

Commenting on the training policies and resources, one college manager felt that the lack of a mandatory education scheme was enlarging the public-private gap in awareness and standards of patient-centred care. Interestingly, one public manager observed some skills and awareness gaps among some private GPs: “Compared to HA

141 doctors who received mandatory training, I have to be honest…some private doctors are out of touch with the latest medical knowledge as they have not been continually educated…” (P9, public GP). Unlike specialists who have to attend 30 hours of training annually on the latest policies, communication and clinical techniques in order to be board certified under the Continued Medical Education Scheme (CME), GPs were not required to attend any ongoing training.

4.3.3 Theme 3: GPs’ perception of how national values influence mutual trust in the GP-patient relationship regarding mutual participation in treatment decisions

The third theme examines how the wider societal culture caused conflicting expectations among older and younger patients towards GPs and healthcare services. This disparity influences how GPs establish trust and rapport with different generations, facilitating a patient-centred or doctor-centred consultation style.

4.3.3.1 Subtheme 3.1: Conflicting traditional and modern societal values towards